|Year : 2018 | Volume
| Issue : 4 | Page : 196-202
Effect of ramadan fasting on glycemic control and other essential variables in diabetic patients
Abdülbari Bener1, Abdulla O. A A. Al-Hamaq2, Mustafa Öztürk3, Funda Çatan4, Parvez I Haris5, Kaleem U Rajput6, Abdülkadir Ömer3
1 Department of Biostatistics and Medical Informatics, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul; Department of Evidence for Population Health Unit, School of Epidemiology and Health Sciences, The University of Manchester, Manchester, UK; Department of Endocrinology, Regenerative and Resorative Medicine Research Centre, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
2 Qatar Diabetic Association and Qatar Foundation for Research, Doha, Qatar
3 Department of Endocrinology, Regenerative and Resorative Medicine Research Centre, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
4 Department of Biostatistics and Medical Informatics, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul; Department of Computer Education and Instructional Technologies, Faculty of Education, University of Kastamonu, Kastamonu, Turkey
5 Department School of Allied Health Sciences, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
6 Department of Biomedical Science, Faculty of Medicine, Health Care and Social Sciences, St George's University of London, London, UK
|Date of Web Publication||24-Dec-2018|
Prof. Abdülbari Bener
Department of Biostatistics and Medical Informatics, Cerrahpasa Faculty of Medicine, International School of Medicine, Istanbul University and Istanbul Medipol University, 34098 Cerrahpasa, Istanbul
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Fasting during the holy month of Ramadan is a religious obligation for all Muslims who represent 1.8 billion of the world population (24%). This study explores the effect of Ramadan fasting on the blood glucose, glycated hemoglobin (HbA1c), lipid profile, sleeping quality, and essential lifestyle parameters and also explores the safety of fasting for a whole month among diabetic patients. Aim: The aim of the present study was to assess the impact of Ramadan fasting on the blood glucose, HbA1c, lipid profile, sleeping quality, and lifestyle parameters among patients with type 2 diabetes mellitus (T2DM) in Turkey. Subjects and Methods: A total of 1780 diabetic patients were approached, and 1246 (70%) participated in this cross-sectional study carried out during the period from May 27, 2017, to June 24, 2017. Data analysis comprised sociodemographic features, lifestyle habits, blood pressure measurements, serum lipid profiles, serum calcium, Vitamin D 25-hydroxy, uric acid, and HbA1c at before 4 weeks and after 12 weeks from Ramadan. Results: Out of 1246 patients, 593 (47.6%) were male and 653 (52.4%) were female. The mean ± standard deviation age of the patients was 50.39 ± 15.3 years. Males were significantly older than females (51.53 ± 12.56 vs. 49.26 ± 14.4; P = 0.003, respectively). Significant differences were found in Vitamin D, blood glucose, HbA1c level, creatinine, bilirubin, albumin, total cholesterol, triglycerides, high-density lipoprotein-cholesterol (female), low-density lipoprotein-cholesterol (male), uric acid, and systolic and diastolic blood pressure after and before the holy month of Ramadan (P < 0.05 for each). HbA1c (P < 0.001), physical activity (P < 0.001), hours of sleeping (P < 0.001), systolic blood pressure (BP) (mmHg) (P = 0.007), BMI (P = 0.016), diastolic BP (mmHg) (P = 0.018), family history (P = 0.021), and smoking (P = 0.045) were identified as significantly associated with Ramadan fasting as contributing factors. Conclusion: In one of the largest studies of its kind, we show that Ramadan fasting has positive effects on T2DM patients as it reduces their blood pressure, blood glucose, HbA1C, and BMI. Furthermore, there are improvements in the duration of sleep and physical activity, the role of Ramadan fasting in diabetes therapy has been confirmed.
| Abstract in French|| |
Contexte: Le jeûne pendant le mois sacré du Ramadan est une obligation religieuse pour tous les musulmans qui représentent 1,8 milliard de personnes dans le monde population (24%). Cette étude explore l'effet du jeûne du Ramadan sur la glycémie, l'hémoglobine glyquée (HbA1c), le profil lipidique, qualité de sommeil, et les paramètres essentiels de style de vie et explore également la sécurité du jeûne pour un mois entier chez les patients diabétiques. But: Le but de la présente étude était d'évaluer l'impact du jeûne du Ramadan sur la glycémie, l'HbA1c, le profil lipidique, le sommeil paramètres de qualité et de style de vie chez les patients atteints de diabète sucré de type 2 (DT2) en Turquie. Sujets et méthodes: Un total de 1780 patients diabétiques ont été approchés, et 1246 (70%) ont participé à cette étude transversale réalisée au cours de la période Du 27 mai 2017 au 24 juin 2017. L'analyse des données comprenait des caractéristiques sociodémographiques, des habitudes de vie, des mesures de la tension artérielle, les profils sériques des lipides, le calcium sérique, la vitamine D 25-hydroxy, l'acide urique et l'HbA1c avant 4 semaines et après 12 semaines de Ramadan. Résultats: Sur 1246 patients, 593 (47,6%) étaient des hommes et 653 (52,4%) étaient des femmes. L'âge moyen ± écart-type des patients était de 50,39 ± 15,3 ans. Les mâles étaient significativement plus âgés que les femelles (51,53 ± 12,56 contre 49,26 ± 14,4, P = 0,003, respectivement). Important différences ont été trouvées dans la vitamine D, la glycémie, le taux d'HbA1c, la créatinine, la bilirubine, l'albumine, le cholestérol total, les triglycérides, la densité lipoprotéine-cholestérol (femelle), lipoprotéine-cholestérol de basse densité (mâle), acide urique et tension artérielle systolique et diastolique après et avant le mois sacré du Ramadan (P <0,05 pour chacun). HbA1c (P < 0,001), activité physique (P <0,001), heures de sommeil (P <0,001), tension artérielle systolique (TA) (mmHg) (P = 0,007), IMC (P = 0,016), TA diastolique (mmHg) (P = 0,018), antécédents familiaux (P = 0,021), et le tabagisme (P = 0,045) a été identifié comme étant significativement associé au jeûne du Ramadan en tant que facteurs contributifs. Conclusion: Dans l'un des les plus grandes études de son genre, nous montrons que le jeûne du Ramadan a des effets positifs sur les patients atteints de DT2 car il réduit leur tension artérielle, le sang glucose, HbA1C et BMI. En outre, il y a des améliorations dans la durée du sommeil et de l'activité physique, le rôle du jeûne du Ramadan dans la thérapie du diabète a été confi rmée.
Mots-clés: Indice de masse corporelle, diabète sucré, hémoglobine glyquée, jeûne du Ramadan, qualité de sommeil
Keywords: Body mass index, diabetes mellitus, glycated hemoglobin, Ramadan fasting, sleeping quality
|How to cite this article:|
Bener A, A. Al-Hamaq AO, Öztürk M, Çatan F, Haris PI, Rajput KU, Ömer A. Effect of ramadan fasting on glycemic control and other essential variables in diabetic patients. Ann Afr Med 2018;17:196-202
|How to cite this URL:|
Bener A, A. Al-Hamaq AO, Öztürk M, Çatan F, Haris PI, Rajput KU, Ömer A. Effect of ramadan fasting on glycemic control and other essential variables in diabetic patients. Ann Afr Med [serial online] 2018 [cited 2019 Jun 18];17:196-202. Available from: http://www.annalsafrmed.org/text.asp?2018/17/4/196/248398
| Introduction|| |
Ramadan fasting is one of the five main pillars of Islam that is practiced by over one and a half billion people.,, Fasting during Ramadan is a mandatory duty for all healthy sane Muslims, and they should endure without food, drink, oral medications, smoking, and other sensual pleasures from break of dawn to sunset.,,,,,,
Numerous studies have mentioned the biochemical alterations while fasting among both in nondiabetic patients and diabetic patients.,,,,,, The population-based Epidemiology of Diabetes and Ramadan 1422/2001 study performed among 12,243 people in 13 Islamic countries and reported that approximately 43% of Muslims with type 1 diabetes and 79% of Muslims with type 2 diabetes fast during Ramadan. Furthermore, more than 50 million Muslims who have diabetes fast during Ramadan.
Diabetes mellitus, and cardiovascular diseases,,, are reaching epidemic proportions worldwide and lead to important public and personal burden. Furthermore, diabetes mellitus is a primary reason of mortality and morbidity in many developed and developing countries.,, Ramadan fasting change lifestyle of Muslims for one lunar month that may have an impact on diabetic and cardiac patients,,,, because during the Ramadan Muslims eat meals before dawn and after sunset. The alteration in meal schedule has an effect on sleep habit, lifestyle properties, and diabetes complications.,,,,, The aim of the present study was to assess the impact of Ramadan fasting on the blood glucose, glycated hemoglobin (HbA1c), lipid profile, sleeping quality, and lifestyle parameters among patients with type 2 diabetes mellitus (T2DM) in Turkey.
| Subjects and Methods|| |
This cross-sectional study was conducted among Turkish adult patients with T2DM in the Medipol Hospitals. Institutional Review Board ethical clearance for this study was given by the International School of Medicine, Istanbul Medipol University. The study comprised patients with T2DM who treated at the Medipol International Hospital at the time of the study. The diagnosis of DM was assigned by the documentation in the patient's previous or current medical records.,,
The study design was a nonrandomized interventional controlled from May 27, 2017 to June 24, 2017 in two periods as follows: first period (4 weeks before Ramadan) and the second period (4 weeks after Ramadan). The exclusion criteria of the current study were serious comorbidities such as renal diseases, alertness problems, newly diagnosed T2DM (18 months), hospitalization a short time ago, unawareness of hypoglycemia, and partially or completely nonfasting during the month of Ramadan.
The sample size calculation was based on previous studies that determined the prevalence of T2DM and MetSyn in Turkey, to be between 16.2%, with the 99% confidence level and with 2.5% error of estimation, the minimum sample size for the current study was 1780. Patients were recruited by the systematic 1-in-2 sampling procedure. Although 1780 patients were approached, 1246 (70%) patients agreed to participate in this study. One hundred patients were used to determine content validity, face validity, and reliability of the questionnaire. The questionnaire has a high level of validity and a high degree of repeatability (κ = 0.86).
Data collection methods: Questionnaire
This research comprised sociodemographic and lifestyle characteristics such as age, gender, marital status, level of education, occupation, Body Mass Index (BMI), physical activity, the frequency of fast food consumption, and smoking habits, clinical data including systolic and diastolic blood pressures (DBP). Laboratory investigations were performed to examine blood glucose, HbA1c, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), cholesterol, triglyceride, urea, creatinine, bilirubin, albumin, calcium, Vitamin D 25-hydroxy (25-OH), and uric acid before and after Ramadan. BMI was calculated as the ratio of weight (kilogram) to the square of height (meters). The patient was classified as obese if the value of BMI was ≥30 kg/m2, overweight if BMI was >25 kg/m2, and normal if BMI <20 kg/m2., In line with the World Health Organization guidelines, hypertension was evaluated as systolic blood pressure ≥130 mmHg or DBP ≥85 mmHg or using anti-hypertensive medication.,, Smoking habits were classified as being past, current smoker or nonsmoker. Patients were categorized as physically active if they walked or cycled for more than 30 min a day.
After 10 h of fasting, blood sample (10 ml) were collected from the patients. Subsequently, different blood parameters were determined in a central certified laboratory at the Medipol Hospital. Plasma glucose, total cholesterol, triglyceride, HDL-C, and LDL-C were measured using an auto-analyzer (ROCHE COBAS 6000). A high-performance liquid chromatography method was used to evaluate HbA1c concentration.,
Student's paired t-test was performed to specify the differences between biochemistry parameters 4 weeks before and 12 weeks after while the Wilcoxon signed-rank test was used for the nonparametric dataset. Chi-square and Fisher's exact tests were used to determine for differences in proportions of categorical variables between two or more groups. A multivariable linear regression model with step-wise elimination was performed to evaluate the association between dependent and independent variables and to predict potential factors for diabetes. Statistical significance was accepted at the P < 0.05 level.
| Results|| |
[Table 1] presents sociodemographic and lifestyle characteristics of the participants (n = 1246). Out of 1246 patients, 593 (47.6%) were male and 653 (52.4%) were female. The mean ± standard deviation (SD) age of the participants was 50.39 ± 15.3 years. Males were significantly older than females (51.53 ± 12.56 vs. 49.26 ± 13.4; P = 0.003, respectively). There were significant differences between females and males in the level of education, occupation, smoking status, physical, and sporting activity.
|Table 1: Comparison of sociodemographic characteristics of the participants in Istanbul, Turkey (n=1246)|
Click here to view
[Table 2] presents the mean of biochemical characteristics and blood pressures among males and females before 4 weeks and after 12 weeks of Ramadan. The significant differences were found in serum Vitamin D 25-OH, blood glucose, HbA1c level, creatinine, bilirubin, albumin, total cholesterol, triglycerides, HDL-C (female), LDL-C (male), uric acid, systolic and DBP before and after Ramadan (P < 0.05 for each). Furthermore, there were significant differences in the number of sleeping hours between during and after Ramadan (5.61 ± 0.58 vs. 6.93 ± 0.72; P < 0.001, respectively).
|Table 2: The comparison of biochemical characteristics and blood pressures among males and females before and after Ramadan (n=1246)|
Click here to view
[Table 3] shows the comparison of average biochemical characteristics and blood pressures among the participants before 4 weeks and after 12 weeks of Ramadan. There were significant differences Vitamin D 25-OH, blood glucose, HbA1c level, calcium, creatinine, albumin, total cholesterol, HDL-C, LDL-C, uric acid, systolic and DBP, hours of sleep, and BMI before and after Ramadan (P < 0.001 for each).
|Table 3: The comparison of biochemical characteristics and blood pressures among patients before and after Ramadan (n=1246)|
Click here to view
[Table 4] shows the results of multiple linear regression analysis to indicate predictors and impact of Ramadan fasting on several biochemical and lifestyle parameters in diabetic patients. As can be seen from this table, HbA1c (P < 0.001), physical activity (P < 0.001), hours of sleeping (P < 0.001), systolic BP (mmHg) (P = 0.007), obesity (P = 0.016), diastolic BP (mmHg) (P = 0.018), family history (P = 0.021), and smoking (P = 0.045) were significantly associated with Ramadan fasting as contributing factors.
|Table 4: Multivariable linear regression analysis to show predictors and effect of Ramadan fasting on different biochemical and anthropometric parameters in diabetic patients|
Click here to view
| Discussion|| |
In Turkey, a large proportion of patients with diabetes mellitus fast regularly during Ramadan. Ramadan fasting is a challenge for diabetic patients because of the acute changes in their dietary and lifestyle patterns. Therefore, it is difficult to suggest a treatment for this group of people. The number of studies on Ramadan fasting T2DM patients from Turkey is limited and has been restricted to using few patients, with the largest study using 122 patients. In this context, the current study is much larger as it recruited 1246 T2DM patients. The present study, with a much larger number of patients, revealed the favorable impact of Ramadan fasting on the important parameters of diabetes including blood glucose, HbA1c levels, and lipid profile. The results are consistent with previous studies reported in the literature.,,,,,,,,,,,,,, In patients with T2DM, diet, exercise, and antidiabetic medications can help stabilize blood glucose level. However, any alteration can fluctuate the blood glucose level and lead to hyperglycemia or hypoglycemia.,, A previous small study (n = 122) investigated Turkish patients with T2DM before and after Ramadan. It did not find any negative effects of fasting on this group of patients. This is in agreement with our much larger study (1246 T2DM patients). Therefore, the current evidence suggests that Ramadan fasting is unlikely to be risky for well-controlled patients.,,,,,,, According to previous studies, Ramadan fasting had no negative impacts on glucose regulation of patients with T2DM who use antidiabetic medications.,,,,,,,,,, This is in good agreement with our study. The findings from our study revealed that fasting leads to a statistically significant reduction in blood glucose levels that were consistent with other studies.,, It has been previously reported that weight loss is important for improving the health status of T2DM patients. For example, weight loss has been found to be a stronger predictor of HbA1c goal attainment in T2DM compared to medication adherence. The finding of this study revealed that after the month of Ramadan fasting there is a significant decrease in body weight which could beneficial for T2DM patients and Ramadan fasting could play a role in diabetes therapy. There is now consensus that physical activity can be beneficial for diabetes as it can improve various risk factors associated with diabetes including blood glucose level. The study reveals that compared to before Ramadan, there is a statistically significant increase in physical activity after Ramadan. The precise reason for this change is not clear, but the reduction in body weight and the improvement in blood parameters may have some contributory roles. In addition to improvements in blood parameters, Ramadan fasting led to a statistically significant increase in the duration of sleep compared to before Ramadan. This is important since there is insufficient sleep duration is associated with a poor glycemic control in T2DM.
In a comprehensive study, several suggestions have been recommended for patients with diabetes mellitus. The suggestions were blood glucose monitoring, consultation with their physicians, not skipping predawn meal, not doing tiring exercises, and regulation of medication dose. Monitoring plasma glucose during Ramadan fasting is a difficult issue for doctors and patients. The plasma glucose levels are determined by food intake, physical activity, and medications. Patients with T2DM should be recommended to monitor blood glucose regularly throughout the fasting month.
| Conclusion|| |
The current study represents the largest study (n = 1246) with Turkish T2DM patients to explore the impact of Ramadan fasting on different biochemical and lifestyle parameters. We found significant differences between Ramadan fasting and decrease in blood lipid profile, blood pressure, blood glucose, HbA1c levels, BMI, and sleeping problems among patients with T2DM. The study suggests that Muslim diabetic patients can fast during Ramadan after consultation with their physicians. Indeed, Ramadan fasting can be considered as a strategy for managing and improving the health of diabetic patients.
This work was generously supported and funded by the Qatar Diabetes Association, Qatar Foundation. The authors would like to thank the Cerrahpaşa Faculty of Medicine and Medipol International School of Medicine, Istanbul Medipol University for their support and ethical approval (RP# 10840098-604.01-E.3192).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khan N, Khan MH, Shaikh MZ, Khanani MR, Rasheed A. Effects of Ramadan fasting and physical activity on glucose levels and serum lipid profile among type 2 diabetic patients. Pak J Med Sci 2012;28:91-6.
Salti I, Bénard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, et al.
A population-based study of diabetes and its characteristics during the fasting month of ramadan in 13 countries: Results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004;27:2306-11.
Bener A, Yousafzai MT. Effect of Ramadan fasting on diabetes mellitus: A population-based study in Qatar. J Egypt Public Health Assoc 2014;89:47-52.
Lamri-Senhadji MY, El Kebir B, Belleville J, Bouchenak M. Assessment of dietary consumption and time-course of changes in serum lipids and lipoproteins before, during and after Ramadan in young Algerian adults. Singapore Med J 2009;50:288-94.
Sahin SB, Ayaz T, Ozyurt N, Ilkkilic K, Kirvar A, Sezgin H, et al.
The impact of fasting during Ramadan on the glycemic control of patients with type 2 diabetes mellitus. Exp Clin Endocrinol Diabetes 2013;121:531-4.
Karatoprak C, Yolbas S, Cakirca M, Cinar A, Zorlu M, Kiskac M, et al.
The effects of long term fasting in Ramadan on glucose regulation in type 2 diabetes mellitus. Eur Rev Med Pharmacol Sci 2013;17:2512-6.
Chentli F, Azzoug S, Amani Mel A, Elgradechi A. Diabetes mellitus and Ramadan in Algeria. Indian J Endocrinol Metab 2013;17:S295-8.
Khan N, Rasheed A, Ahmed H, Aslam F, Kanwal F. Effect of Ramadan fasting on glucose level, lipid profile, hbA1c and uric acid among medical students in Karachi, Pakistan. East Mediterr Health J 2017;23:274-9.
Al Suwaidi J, Bener A, Hajar HA, Numan MT. Does hospitalization for congestive heart failure occur more frequently in Ramadan: A population-based study (1991-2001). Int J Cardiol 2004;96:217-21.
Al Suwaidi J, Bener A, Gehani AA, Behair S, Al Mohanadi D, Salam A, et al.
Does the circadian pattern for acute cardiac events presentation vary with fasting? J Postgrad Med 2006;52:30-3.
Bener A, Azhar A, Bessisso M. Do fasting and life style eating habits in Ramadan affect headache? Nutr Food Sci 2007;37:427-33.
Bener A, Galadari S, Gillett M, Osman N, Al Taneji H, Al-Kuwaiti MH, et al
. Fasting during the holy month of Ramadan does not change the composition of breast milk. Nutr Res 2001;21:859-64.
Ismail NA, Olaide Raji H, Abd Wahab N, Mustafa N, Kamaruddin NA, Abdul Jamil M, et al.
Glycemic control among pregnant diabetic women on insulin who fasted during Ramadan. Iran J Med Sci 2011;36:254-9.
Velayudhan M. Managing diabetes during the Muslim fasting month of Ramadan. Med J Malaysia 2012;67:353-4.
Bener A, Keskin FE, Kurtulus EM, Guzel M, Çekirdekçi EI, Kadıoğlu P, Konukoğlu D, Öztürk M. Essential parameters and risk factors of the patients for diabetes care and treatment. Diabetes Metab Syndr. 2017;11 Suppl 1:S315-20. Doi: 10.1016/j.dsx.2017.03.008.
Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: Diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15:539-53.
Sözmen K, Unal B, Capewell S, Critchley J, O'Flaherty M. Estimating diabetes prevalence in turkey in 2025 with and without possible interventions to reduce obesity and smoking prevalence, using a modelling approach. Int J Public Health 2015;60 Suppl 1:S13-21.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult treatment panel III) final report. Circulation 2002;106:3143-421.
Katibi IA, Akande AA, Bojuwoye BJ, Okesina AB. Blood sugar control among fasting muslims with type 2 diabetes mellitus in Ilorin. Niger J Med 2001;10:132-4.
Khatib FA, Shafagoj YA. Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake. Saudi Med J 2004;25:1858-63.
Rehman J, Shafiq M. Changes in blood glucose and lipid profile during Ramdan fasting. JAMC 2000;12:13-5.
Al Suwaidi J, Bener A, Suliman A, Hajar R, Salam AM, Numan MT, et al.
A population based study of Ramadan fasting and acute coronary syndromes. Heart 2004;90:695-6.
Bener A, Hamad A, Fares A, Al-Sayed HM, Al-Suwaidi J. Is there any effect of Ramadan fasting on stroke incidence? Singapore Med J 2006;47:404-8.
Anderson JW, Kendall CW, Jenkins DJ. Importance of weight management in type 2 diabetes: Review with meta-analysis of clinical studies. J Am Coll Nutr 2003;22:331-9.
McAdam-Marx C, Bellows BK, Unni S, Mukherjee J, Wygant G, Iloeje U, et al.
Determinants of glycaemic control in a practice setting: The role of weight loss and treatment adherence (The DELTA study). Int J Clin Pract 2014;68:1309-17.
Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, et al.
Exercise and type 2 diabetes: The American college of sports medicine and the American Diabetes Association: Joint position statement. Diabetes Care 2010;33:e147-67.
Lee SWH, Ng KY, Chin WK. The impact of sleep amount and sleep quality on glycemic control in type 2 diabetes: A systematic review and meta-analysis. Sleep Med Rev 2017;31:91-101.
Ibrahim M, Abu Al Magd M, Annabi FA, Assaad-Khalil S, Ba-Essa EM, Fahdil I, et al.
Recommendations for management of diabetes during Ramadan: Update 2015. BMJ Open Diabetes Res Care 2015;3:e000108.
[Table 1], [Table 2], [Table 3], [Table 4]